Success Treatment of Severe and Active Graves' Orbitopathy with Tocilizumab After Thyroidectomy and Maximum Dose of Intravenous Methylprednisolone

We report a woman, 45th year old with Graves' disease treated with anti-thyroid drug (thiamazole). She came to our clinic with severe and active Graves' orbitopathy. We treated her with high dose intravenous methylprednisolone weekly (0.5 g weekly/ 6 weeks) and mycophenolate sodium 0.72 g daily/ 6 weeks. Because of her longterm consumption but not successful to achieve remission of anti-thyroid drugs and the size of her goiter, we decided to do total thyroidectomy. Only one week after thyroidectomy, her eye inflammation grade was reduced, but still bulging. We continue with the intravenous methylprednisolone weekly. Because of the partial response, we continue with another dose of methylprednisolone (0.25 g weekly for another 6 weeks).After 12 weeks of intravenous methylprednisolone (maximum dose for 1st course 4.5 g), there is a partial response make it to moderate to severe grade but still active inflammation. Our team decided to give her second-line treatment and we give her intravenous tocilizumab monthly for 4 weeks. After three tocilizumab infusion, the inflammation is reduced remarkably. Her overall appearance is getting better. But, because of her sight was not improved much as the inflammation reduced, we done orbital MRI and we decided to do another intravenous methylprednisolone 1 g for three days followed by orbital decompresion surgery. Shortly after the orbital decompresion, her sight was improved very well. She can now doing activities she can do previously. After recovery, we plan to give her the fourth (last) tocilizumab infusion. Overall, tocilizumab improves clinical outcome in patient with active corticosteroid-resistant moderate to severe Graves' orbitopathy. Patient's quality of life also improved.

Intravenous Immunoglobulin Responsive Persistent Thrombocytopenia after Dengue Haemorrhagic Fever

Dengue outbreak is common in Indian subcontinent and causes significant morbidity and mortality. Year 2015 has witnessed yet another Dengue epidemic in northern India and the number of cases this year is maximum in a decade. Dengue infection is a viral disease and there are 4 different serotypes DENV1, DENV2, DENV3 and DENV4. This year DENV2 and DENV4 have been isolated from most of the patients. Thrombocytopenia is hallmark of dengue infection and generally recovers within ten days of onset of symptoms. We report a case of dengue haemorrhagic fever in which thrombocytopenia persisted for almost a month and improved after Intravenous immunoglobulin (IVIG) administration. This is the first case where IVIG has been successfully used for treating persisting thrombocytopenia after dengue infection.

Management of paradoxical response in pediatric tubercular meningitis with methylprednisolone

Paradoxical response to anti-tubercular drugs remains a diagnostic dilemma. In India where tuberculosis is quite prevalent, paradoxical response to anti-tubercular treatment (ATT) is either misdiagnosed or under-diagnosed. We report two cases of optochiasmatic arachnoiditis due to paradoxical response in children suffering from tuberculous meningitis. Visual acuity was recorded as no light perception in all eyes of both patients while they were taking 4-drug ATT (isoniazid, rifampicin, pyrazinamide and ethambutol). However their systemic conditions did not worsen. They were treated with intravenous methylprednisolone for five days followed by systemic corticosteroids on a tapering dose for four weeks along with ATT. This case report highlights the importance of early recognition of this sight-threatening complication and timely, effective treatment to prevent permanent blindness.